Practice Management Alert

Question: Our doctor saw a patient in the emergency room and decided to admit him and perform surgery. This patient is not Medicare. Do I code this using 99221-99223, as an outpatient E/M code, or with an emergency room E/M code? Also do I need to add a modifier if our doctor is the admitting physician?

Missouri Subscriber

Answer: You should use 99221-99223 (Initial hospital care ...), assuming that your surgeon's documentation will support the code. Once the patient is in inpatient status (per the hospital), you can no longer use outpatient codes.

Since this is not a Medicare patient, you do not need a modifier unless your physician is taking the patient to the operating room or going to do a minor procedure. If he takes the patient to the operation room, append modifier 57 (Decision for surgery). For a minor procedure, use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). If the patient is in the global period of a procedure you'll need to append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period).

Don't miss: You may also need to append the AI modifier (Principal physician of record). While that modifier was created for Medicare, some other payers are requiring it as well. For example, Washington Medicaid requires you to append AI when the patient has both Medicare and Medicaid but not for patients with Medicaid only. Make sure you know what your payers want and follow those rules when submitting claims.